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Background Transverse abdominis plane (TAP) block is considered an effective alternative to neuraxial analgesia for abdominal surgery. However, limited evidence supports its use over traditional analgesic modalities in colorectal surgery. This study compared the analgesic efficacy of liposomal bupivacaine TAP block with intrathecal (IT) opioid administration in a multicentre RCT. Methods Patients undergoing elective small bowel or colorectal resection were randomized to receive TAP block or a single injection of IT analgesia with hydromorphone. Patients were assessed at 4, 8, 16, 24 and 48 h after surgery. Primary outcomes were mean pain scores and morphine milligram equivalents (MMEs) administered within 48 h after surgery. Secondary outcomes included duration of hospital stay, incidence of postoperative ileus and use of intravenous patient-controlled analgesia. Results In total, 209 patients were recruited and 200 completed the trial (TAP 102, IT 98). The TAP group had a 1·6-point greater mean pain score than the IT group at 4 h after surgery, and this difference lasted for 16 h after operation. The TAP group received more MMEs within the first 24 h after surgery than the IT group (median difference in MMEs 10·0, 95 per cent c.i. 3·0 to 20·5). There were no differences in MME use at 24 and 48 h, or with respect to secondary outcomes. Conclusion IT opioid administration provided better immediate postoperative pain control than TAP block. Both modalities resulted in low pain scores in patients undergoing elective colorectal surgery and should be considered in multimodal postoperative analgesic plans. Registration number: NCT02356198 ( http://www.clinicaltrials.gov).

The need to identify and effectively treat COVID-19 cases at highest risk for severe disease remains critical. We identified five common genetic loci (two novel) that modulate both COVID-19 susceptibility and severity, implicating TMPRSS2, IFNAR2, CCHCR1, TCF19 and SLC6A20 as potential targets. A high genetic burden was strongly associated with increased risk of hospitalization and severe disease among COVID-19 cases, especially among individuals with few known clinical risk factors.

A relationship between intracranial and abdominal aortic aneurysms (AAA) has been appreciated through genome-wide association studies suggesting a shared pathophysiology. However, the actual prevalence of AAA in patients presenting with ruptured intracranial aneurysms is not known. Our aim was to estimate the prevalence of previously undiagnosed AAA in patients presenting with aneurysmal subarachnoid hemorrhage (aSAH) to see if it may be high enough to justify formally testing the utility of screening.A prospective, observational inception cohort study of 81 consecutive patients presenting to Mayo Clinic Florida with aSAH was performed from August 14, 2011 to February 10, 2014. These individuals were then screened using an abdominal ultrasound technique for an AAA. Our primary end point was detection of AAA. Our secondary end points were 30-day good-to-fair functional status (modified Rankin scale 4) and all-cause mortality.We detected an AAA in 10 patients (rate: 12%; 95% CI 6-22%) with aSAH. The mean diameter of these AAA was 3.4 ± 1.0 cm. Among these 10 patients, there was one death within the first month of aSAH hospitalization. There were no significant differences in demographic or clinical characteristics based on AAA detection status. Mean follow-up time was 4.7 years. The rate of good-to-fair functional status at 30-days was 79%. All-cause mortality during follow-up at 1-year was higher for patients with AAA (36%; 95% CI 0-61%) compared to patients without AAA (7%; 95% CI 1-14%) (log-rank p = 0.045).The co-prevalence of AAA in patients presenting with ruptured brain aneurysms may be sufficiently high such that screening for AAA among likely survivors of aSAH might be appropriate. Larger studies would be needed to establish a net clinical benefit from screening AAA and then treating newly identified large AAAs in this morbid population.

Aims/hypothesis Although cardiovascular disease is the biggest cause of death in people with diabetes, microvascular complications have a significant impact on quality of life and financial burden of the disease. Little is known about the progression of microvascular dysfunction in the early stages of type 2 diabetes before the occurrence of clinically apparent complications. We aimed to explore the determinants of endothelial-dependent and -independent microvascular function progression over a 3 year period, in people with and without both diabetes and few clinical microvascular complications. Methods Demographics were collected in 154 participants with type 2 diabetes and in a further 99 participants without type 2 diabetes. Skin microvascular endothelium-dependent response to iontophoresis of acetylcholine and endothelium-independent responses to sodium nitroprusside were measured using laser Doppler fluximetry. All assessments were repeated 3 years later. Results People with type 2 diabetes had impaired endothelial-dependent microvascular response compared with those without (AUC 93.9 [95% CI 88.1, 99.4] vs 111.9 [102.3, 121.4] arbitrary units [AU] × min, p p = 0.002). Mean microvascular function declined over 3 years in both groups to a similar degree (pinteraction 0.74 for response to acetylcholine and 0.69 for response to sodium nitroprusside). In those with diabetes, use of sulfonylurea was associated with greater decline (p = 0.022 after adjustment for co-prescriptions, change in HbA1c and weight), whereas improving glycaemic control was associated with less decline of endothelial-dependent microvascular function (p = 0.03). Otherwise, the determinants of microvascular decline were similar in those with and without diabetes. The principal determinant of change in microvascular function in the whole population was weight change over 3 years, such that those that lost ≥5% weight had very little decline in either endothelial-dependent or -independent function compared with those that were weight stable, whereas those who gained weight had a greater decline in function (change in endothelial-dependent function was 1.2 [95% CI −13.2, 15.7] AU × min in those who lost weight; −15.8 [−10.5, −21.0] AU × min in those with stable weight; and −37.8 [−19.4, −56.2] AU × min in those with weight gain; ptrend Conclusions/interpretation Over 3 years, physiological change in weight was the greatest predictor of change in microvascular function.

We have commissioned a new time-resolved, x-ray imaging diagnostic for the Z facility. The primary intended application is for diagnosing the stagnation behavior of Magnetized Liner Inertial Fusion (MagLIF) and similar targets. We have a variety of imaging systems at Z, both time-integrated and time-resolved, that provide valuable x-ray imaging information, but no system at Z up to this time provides a combined high-resolution imaging with multi-frame time resolution; this new diagnostic, called TRICXI for Time Resolved In-Chamber X-ray Imager, is meant to provide time-resolved spatial imaging with high resolution. The multi-frame camera consists of a microchannel plate camera. A key component to achieving the design goals is to place the instrument inside the Z vacuum chamber within 2 m of the load, which necessitates a considerable amount of x-ray shielding as well as a specially designed, independent vacuum system. A demonstration of the imaging capability for a series of MagLIF shots is presented. Predictions are given for resolution and relative image irradiance to guide experimenters in choosing the desired configuration for their experiments.

Background In a care under fire situation, a first line response to haemorrhage is to apply a tourniquet and return fire. However, there is little understanding of how tourniquets and other haemorrhage control devices impact marksmanship. Methods We compared the impact of the iTClamp and the Combat Application Tourniquet (CAT) on marksmanship. Following randomisation (iTClamp or CAT), trained marksmen fired an AR15 at a scaled silhouette target in prone unsupported position (shooting task). Subjects then attempted to complete the shooting task at 5, 10, 15, 30 and 60 min post-haemorrhage control device application. Results All of the clamp groups (n=7) completed the 60 min shooting task. Five CAT groups (n=6) completed the 5 min shooting task and one completed the 5 and 10 min shooting task before withdrawing. Four CAT groups were stopped due to unsafe handling; two stopped due to pain. When examining hits on mass (HOM) for the entire shooting task, there was no significant difference between tourniquet and iTClamp HOM at 5 min (p=0.18). However, there was a significant difference at 10 min, p=0.003 with tourniquet having significantly fewer HOM (1.7±2.7 HOM) than the iTClamp (8.1±3.3 HOM) group. The total effective HOM for the entire 60 min shooting task showed that the iTClamp group achieved significantly (p=0.001) more HOM than the tourniquet group. Over the entire 60 min shooting exercise, the iTClamp group achieved a median 72% (52/72) of available HOM while the tourniquet group obtained 19% (14/72). Conclusions Application of a tourniquet to the dominant arm negates effective return of fire in a care under fire setting after a brief time window. Haemorrhage control devices that preserve function may have a role in care under fire situations, as preserving effectiveness in returning fire has obvious operational merits.

Pulsed power accelerators compress electrical energy in space and time to provide versatile experimental platforms for high energy density and inertial confinement fusion science. The 80-TW “Z” pulsed power facility at Sandia National Laboratories is the largest pulsed power device in the world today. Z discharges up to 22 MJ of energy stored in its capacitor banks into a current pulse that rises in 100 ns and peaks at a current as high as 30 MA in low-inductance cylindrical targets. Considerable progress has been made over the past 15 years in the use of pulsed power as a precision scientific tool. This paper reviews developments at Sandia in inertial confinement fusion, dynamic materials science, x-ray radiation science, and pulsed power engineering, with an emphasis on progress since a previous review of research on Z in Physics of Plasmas in 2005.

Objective: The aim of this study was to develop a new international classification of acute pancreatitis severity on the basis of a sound conceptual framework, comprehensive review of published evidence, and worldwide consultation. Background: The Atlanta definitions of acute pancreatitis severity are ingrained in the lexicon of pancreatologists but suboptimal because these definitions are based on empiric descriptions of occurrences that are merely associated with severity. Methods: A personal invitation to contribute to the development of a new international classification of acute pancreatitis severity was sent to all surgeons, gastroenterologists, internists, intensive medicine specialists, and radiologists who are currently active in clinical research on acute pancreatitis. The invitation was not limited to members of certain associations or residents of certain countries. A global Web-based survey was conducted and a dedicated international symposium was organised to bring contributors from different disciplines together and discuss the concept and definitions. Result: The new international classification is based on the actual local and systemic determinants of severity, rather than descriptions of events that are correlated with severity. The local determinant relates to whether there is (peri)-pancreatic necrosis or not, and if present, whether it is sterile or infected. The systemic determinant relates to whether there is organ failure or not, and if present, whether it is transient or persistent. The presence of one determinant can modify the effect of another such that the presence of both infected (peri) pancreatic necrosis and persistent organ failure have a greater effect on severity than either determinant alone. The derivation of a classification based on the above principles results in 4 categories of severity - mild, moderate, severe, and critical. Conclusions: This classification is the result of a consultative process amongst pancreatologists from 49 countries spanning North America, South America, Europe, Asia, Oceania, and Africa. It provides a set of concise up-to-date definitions of all the main entities pertinent to classifying the severity of acute pancreatitis in clinical practice and research. This ensures that the determinant-based classification can be used in a uniform manner throughout the world.

We recently developed a one-dimensional imager of neutrons on the Z facility. The instrument is designed for Magnetized Liner Inertial Fusion (MagLIF) experiments, which produce D-D neutrons yields of ∼3 × 1012. X-ray imaging indicates that the MagLIF stagnation region is a 10-mm long, ∼100-μm diameter column. The small radial extents and present yields precluded useful radial resolution, so a one-dimensional imager was developed. The imaging component is a 100-mm thick tungsten slit; a rolled-edge slit limits variations in the acceptance angle along the source. CR39 was chosen as a detector due to its negligible sensitivity to the bright x-ray environment in Z. A layer of high density poly-ethylene is used to enhance the sensitivity of CR39. We present data from fielding the instrument on Z, demonstrating reliable imaging and track densities consistent with diagnosed yields. For yields ∼3 × 1012, we obtain resolutions of ∼500 μm.

A new Wolter x-ray imager has been developed for the Z machine to study the emission of warm (>15 keV) x-ray sources. A Wolter optic has been adapted from observational astronomy and medical imaging, which uses curved x-ray mirrors to form a 2D image of a source with 5 × 5 × 5 mm3 field-of-view and measured 60-300-μm resolution on-axis. The mirrors consist of a multilayer that create a narrow bandpass around the Mo Kα lines at 17.5 keV. We provide an overview of the instrument design and measured imaging performance. In addition, we present the first data from the instrument of a Mo wire array z-pinch on the Z machine, demonstrating improvements in spatial resolution and a 350-4100× increase in the signal over previous pinhole imaging techniques.

Recent breakthroughs in the fabrication of small-radii Wolter optics for astrophysics allow high energy density facilities to consider such optics as novel x-ray diagnostics at photon energies of 15-50 keV. Recently, the Lawrence Livermore National Laboratory, Sandia National Laboratories (SNL), the Smithsonian Astrophysical Observatory, and the NASA Marshall Space Flight Center jointly developed and fabricated the first custom Wolter microscope for implementation in SNL’s Z machine with optimized sensitivity at 17.5 keV. To achieve spatial resolution of order 100-200 microns over a field of view of 5 × 5 × 5 mm3 with high throughput and narrow energy bandpass, the geometry of the optic and its multilayer required careful design and optimization. While the geometry mainly influences resolution and the field of view of the diagnostic, the mirror coating determines the spectral response and throughput. Here we outline the details of the design and fabrication process for the first multilayer-coated Wolter I optic for SNL’s Z machine (Z Wolter), including its W/Si multilayer, and present results of raytrace simulations completed to predict and verify the performance of the optic.

A facility to calibrate x-ray imaging optics was built at Lawrence Livermore National Laboratory to support high energy density (HED) and inertial confinement fusion (ICF) diagnostics such as those at the National Ignition Facility and the Sandia Z-Machine. Calibration of the spectral reflectivity and resolution of these x-ray diagnostics enable absolute determination of the x-ray flux and wavelengths generated in the HED and ICF experiments. Measurement of the optic point spread function is used to determine spatial resolution of the optic. This facility was constructed to measure (1) the x-ray reflectivity to ±5% over a spectral range from 5 to 60 keV; (2) point spread functions with a resolution of 50 μm (currently) and 13 μm (future) in the image plane; and (3) optic distance relative to the x-ray source and detector to within ±100 μm in each dimension. This article describes the capabilities of the calibration facility, concept of operations, and initial data from selected x-ray optics.

A series of transplantable murine colon tumors have been developed from primary tumors induced by dimethylhydrazine. They are moderately- to well-differentiated adenocarcinomas which retain their histologic appearance and growth characteristics through successive transplant generations. The sensitivity of two tumor lines to 11 standard drugs is reported and some correlation shown with the sensitivity of human colorectal tumors to the same drugs. Therapeutic indices are low and each tumor has an individual pattern of sensitivity. The models have potential as secondary drug screening systems and for investigation of factors affecting drug sensitivity.

The lattice parameters of α-alumina have been determined for temperatures in the range 20

Rock varnish from Arizona's Whipple Mountains harbors a microbial community containing about 10 8 microorganisms g −1 of varnish. Analyses of varnish phospholipid fatty acids and rRNA gene libraries reveal a community comprised of mostly Proteobacteria but also including Actinobacteria , eukaryota, and a few members of the Archaea . Rock varnish represents a significant niche for microbial colonization.

The in situ search for life on Mars requires an understanding of the possible habitats available and the types of microbes that inhabit such environments on Earth. Rock varnish is ubiquitous in terrestrial deserts and has been suggested to exist on Mars. Data reported here show that there are very high numbers of bacteria ( 10 7 – 10 8 g −1 dry wt) associated with rock varnish collected in the hot desert of the Whipple Mountains, south of Death Valley, CA, USA. Some of the bacteria identified in the rock varnish from the Whipple Mountains are resistant to UV-C exposure. This suggests that habitats like rock varnish, if they occur in the martian polar regions where liquid water may be available, may provide niches for radiation-resistant life forms such as the bacteria observed in the Whipple Mountains varnish ecosystem. The UV-resistant microbes isolated represent a diverse group of genera, but all are from the order Actinomycetales (the genera Arthrobacter, Curtobacterium, Geodermatophilus, and Cellulomonas). They are metabolically versatile heterotrophs capable of growing on a variety of simple sugars, amino acids, organic acids and aromatic acids as sole carbon and energy sources.

The paper presents two new strategies for bipartitioning circuits based on fuzzy set theory. For this a new fuzzy net-cut model has been developed treating hypergraphs without splitting multi-pin-nets into two-pin-nets. The first approach is based on a stochastic neural network consisting of continuous Hopfield neurons. The second algorithm is derived from statistical physics modelling the circuit graph as a highly coupled spin system.

We describe the design and function of a new time and space resolved x-ray spectrometer for use in Z-pinch inertial confinement fusion and radiation source development experiments. The spectrometer is designed to measure x-rays in the range of 0.5-1.5 A (8-25 keV) with a spectral resolution λ/Δλ ∼ 400. The purpose of this spectrometer is to measure the time- and one-dimensional space-dependent electron temperature and density during stagnation. These relatively high photon energies are required to escape the dense plasma created at stagnation and to obtain sensitivity to electron temperatures ≳3 keV. The spectrometer is of the Cauchois type, employing a large 30 × 36 mm2, transmissive quartz optic for which a novel solid beryllium holder was designed. The performance of the crystal was verified using offline tests, and the integrated system was tested using experiments on the Z pulsed power accelerator.

High quality absorption spectroscopy measurements were recently achieved at the Sandia National Laboratories Z facility in the soft x-ray range. Detailed spectral resolution knowledge is a key requirement for their interpretation. We present a methodology for measuring the wavelength dependent crystal spectral resolution, with a particular focus on the 7–17 A range. We apply this procedure to the case of 1st order resolution of a potassium acid phthalate (KAP) convex crystal spectrometer. One calibration issue is that inferring the crystal resolution requires that the x-ray source emission feature widths and spectral profiles are known. To this aim, we resolve Manson x-ray source Si, Al, and Mg Kα line profiles using a KAP crystal spectrometer in 2nd order to achieve relatively high resolution. This information is exploited to measure 1st order KAP resolving powers λ/Δλ∼1100–1300 in the 7–10 A wavelength range.

Part 1 describes the case of a 74-year-old woman who experienced a worsening of her psychiatric condition shortly after commencing fluoxetine and was found to have a low serum sodium level. The clinical features of hyponatraemia and its causes are reviewed. Part 2 reviews the reports of hyponatraemia and the selective serotonin reuptake inhibitors (SSRIs) and considers the variation in reports between the different SSRIs. Measurement of a patient's electrolytes is recommended if there is a rapid decline in mental state having started on an SSRI.

Hydrogen sulphide is a recently identified endogenous endothelium-dependent vasodilator. Animal models of diabetes have shown that low plasma H2S levels are associated with marked endothelial dysfunction and insulin resistance. However, human studies on H2S and vascular function in health and disease are lacking. Plasma was obtained from male patients with type 2 diabetes (n = 11), overweight (n = 16) and lean (n = 11) volunteers. H2S levels were determined by zinc trap spectrophotometry. Anthropometric measurements (BMI/waist:hip ratio), lipid profile, systemic blood pressure, biochemical indices of diabetes (fasting glucose, insulin sensitivity, Hb1Ac) and microvascular function (minimum vascular resistance) were determined. Median plasma H2S levels (25th, 75th percentiles) in age-matched lean, overweight and type 2 diabetes individuals were 38.9 (29.7, 45.1) µmol/l, 22.0 (18.6, 26.7) µmol/l and 10.5 (4.8, 22.0) µmol/l, respectively. Median plasma H2S levels were significantly lower in patients with type 2 diabetes compared with lean (p = 0.001, Mann–Whitney) and overweight participants (p = 0.008). Median plasma H2S levels in overweight participants were significantly lower than in lean controls (p = 0.003). Waist circumference was an independent predictor of plasma H2S (R 2 = 0.423, standardised beta: −0.650, p

Aims/hypothesis Microvascular dysfunction is associated with end-organ damage. Macular oedema is an important component of diabetic retinopathy. Macular thickness can be accurately quantified by optical coherence tomography (OCT), enabling accurate assessment of the macular prior to clinically apparent abnormalities. We investigated whether macular (fovea) thickness in non-diabetic individuals is related to the microvascular variables controlling fluid filtration across a blood vessel wall, in particular capillary pressure and the microvascular filtration capacity (Kf). Methods We recruited 50 non-diabetic individuals (25 men, 25 women; age range: 26–78 years; BMI range: 20–46 kg/m2). Fovea thickness was assessed by OCT. Microvascular assessments included: finger nailfold capillary pressure; Kf; microvascular structural assessments, i.e. skin vasodilatory capacity, minimum vascular resistance (MVR) and microvascular distensibility; and endothelial function. Results At 214.6 (19.9) µm (mean [SD]), fovea thickness was within normal range. Capillary pressure, adjusted for BMI, was associated with fovea thickness (standardised beta 0.573, p = 0.006, linear regression). Fovea thickness was not associated with Kf, microvascular structural assessments or endothelial function. Capillary pressure was still associated with fovea thickness when adjusted for microvascular variables (Kf, vasodilatory capacity, MVR, microvascular distensibility or endothelial function), or for risk factors for diabetes (systemic blood pressure, insulin sensitivity, inflammation, glycaemic status and lipids) and age. Conclusions/interpretation Capillary pressure, a key determinant of movement of fluid across a blood vessel wall, is associated with fovea thickness in non-diabetic individuals. This suggests that with regard to potential preventative or therapeutic targets, attention should be directed at the mechanisms determining retinal microvascular pressure. Electronic supplementary material The online version of this article (doi:10.1007/s00125-010-1805-x) contains supplementary material, which is available to authorised users.

The incidence of mechanical complications associated with the Nissen fundoplication has prompted evaluation of an anti-reflux procedure designed to be simpler and more physiological, and encompassing a broader view of the many factors involved in the anti-reflux mechanism. Preliminary assessment of the first 100 patients with a mean follow-up of 3–5 years showed symptomatic improvement in 96 per cent and complete relief in 85 per cent. A further 100 patients were studied using formal symptom scoring, endoscopy, manometry and pH monitoring performed before operation and 3 months after operation. Similar clinical results were accompanied by improvement in endoscopic oesophagitis in 95 per cent, complete healing in 74 per cent and restoration of the pH profile to physiological levels in 84 per cent. Troublesome mechanical complications comprised a 2 per cent incidence of dysphagia, but there was no gas bloat or inability to belch or vomit, which may relate to the restoration of lower oesophageal sphincter characteristics close to those of 30 asymptomatic controls. The procedure is simpler to perform than total fundoplication, is well tolerated and is applicable to patients with reflux stricture and impaired oesophageal body motility. The results of this study support the hypotheses that effective reflux control can be achieved without total fundoplication by attention to several factors of known relevance to the anti-reflux mechanism, and that restoration of characteristics of the lower oesophageal sphincter close to physiological levels results in a lower incidence of mechanical complications.

The Care Programme Approach and its accompanying register were introduced in response to difficulties encountered in a young adult population. This paper describes the use of the register by an old age psychiatry service who do not routinely accept ‘graduate’ patients. Few patients had a diagnosis of dementia and most had psychiatric histories in excess of 10 years.

WiMax broadband MAN based on the IEEE 802.16d/e standard offers high data rate scenarios for both mobile and fixed wireless access. Different power control and scheduling options are investigated within the context of interference limited WiMax deployments in tight frequency reuse assuming nomadic mobility. A novel, very promising scheduling approach based on a flexible temporary removal strategy is introduced and analyzed in detail. The temporary removal can be easily combined with conventional scheduling techniques providing considerable performance benefits. Detailed system level simulations have been performed over a wide range of system load scenarios demonstrating a significant throughput and capacity gain of approximately 50% compared to the well-known cyclic/round-robin and maximum CIR schedulers

Adults with type 2 diabetes mellitus have impaired microvascular function. It has been hypothesised that microvascular function may be restored through regular exercise. The aim of this study was to investigate whether 6 months of regular aerobic exercise would improve microvascular function in adults with type 2 diabetes.Fifty-nine patients with type 2 diabetes (32 males, age 62.9+/-7.6 years, HbA(1c) 6.8+/-0.9%) were randomised to either a 6-month aerobic exercise programme (30 min, three times a week, 70-80% of maximal heart rate) or a 'standard care' control group. Before and after the intervention period, microvascular function was assessed as the maximum skin hyperaemia to local heating and endothelial and non-endothelial responsiveness following the iontophoretic application of acetylcholine and sodium nitroprusside. Maximal oxygen uptake, as an index of aerobic fitness, was assessed using a maximal exercise test.No significant improvement was seen in the exercise group compared with the control group for any of the variables measured: maximal oxygen uptake (control pre: 1.73+/-0.53 [means+/-SD] vs post: 1.67+/-0.40; exercise pre: 1.75+/-0.56 vs post: 1.87+/-0.62 l/min, p=0.10); insulin sensitivity (insulin tolerance test) (control pre: -0.17+/-0.06 vs post: -0.17+/-0.06; exercise pre: -0.16+/-0.1 vs post: -0.17+/-0.07 mmol l(-1) min(-1), p=0.97); maximal hyperaemia (control pre: 1.49+/-0.43 vs post: 1.52+/-0.57; exercise pre: 1.42+/-0.36 vs post: 1.47+/-0.33 V, p=0.85); peak response to acetylcholine (control pre: 1.37+/-0.47 vs post: 1.28+/-0.37; exercise pre: 1.27+/-0.44 vs post: 1.44+/-0.23 V, p=0.19) or to sodium nitroprusside (control pre: 1.09+/-0.50 vs post: 1.10+/-0.39; exercise pre: 1.12+/-0.28 vs post: 1.13+/-0.40 V, p=0.98).In this group of type 2 diabetic patients with good glycaemic control a 6-month aerobic exercise programme did not improve microvascular function or aerobic fitness.

In this Article, Professor Carlos A. Ball explores the philosophical foundations for the types of rights and benefits that our society currently provides to individuals with disabilities. The concept of autonomy places on society a moral obligation to assist individuals with disabilities when their basic human functional capabilities are impaired. The exercise of this obligation entails assisting individuals with crossing a minimum threshold of functional capabilities below which it is not possible to lead autonomous lives. In making this argument, Professor Ball responds to libertarian critics who contend that notions of freedom or liberty proscribe an activist role for government in this arena. He explains how even a libertarian state redistributes wealth in order to provide for some incapacities. Professor Ball also disputes the idea that the meeting of the needs of the disabled is enough to provide moral justification for the rights and benefits provided to individuals with disabilities. The problem with the concept of needs, Professor Ball argues, is that it fails to account sufficiently for the human good of personal autonomy.

Insulin resistance is associated with abnormal microvascular function. Treatment with insulin sensitisers may provoke oedema, suggesting microvascular effects. The mechanisms underlying the peripheral oedema observed during glucose-lowering treatment with thiazolidinediones are unclear. Therefore we examined the effect of pioglitazone on microvascular variables involved in oedema formation.Subjects (40-80 years) with type 2 diabetes and on insulin were randomised to 9 weeks of pioglitazone therapy (30 mg/day; n=14) or placebo (n=15). The following assessments were performed at baseline and 9 weeks: microvascular filtration capacity; isovolumetric venous pressure; capillary pressure; capillary recruitment following venous or arterial occlusion; postural vasoconstriction; and maximum blood flow. A number of haematological variables were also measured including vascular endothelium growth factor (VEGF), IL-6 and C-reactive protein (CRP).Pioglitazone did not significantly influence any microcirculatory variable as compared with placebo (analysis of covariance [ANCOVA] for microvascular filtration capacity for the two groups, p=0.26). Mean VEGF increased with pioglitazone (61.1 pg/ml), but not significantly more than placebo (9.76 pg/ml, p=0.94). HbA(1c) levels and the inflammatory markers IL-6 and CRP decreased with pioglitazone compared with placebo (ANCOVA: p=0.009, p=0.001 and p=0.004, respectively).Pioglitazone improved glycaemic control and inflammatory markers over 9 weeks but had no effect on microcirculatory variables associated with oedema or insulin resistance in type 2 diabetic patients treated with insulin.

Extrahepatic biliary atresia is the most common indication for liver transplantation in children. Coexistent congenital anomalies are common (25%), but the combination of polysplenia syndrome (10%) and absence of portal vein is rare.We report a case of successful reduced size liver transplantation on a 13-month-old girl with extrahepatic biliary atresia, polysplenia syndrome and congenital absence of the portal vein.Technical and post-operative problems related to absence of the portal vein and polysplenia are described and the literature reviewed.The donor portal vein was successfully anastomosed to the confluence of the superior mesenteric vein and splenic vein. The child is well with good graft function at a follow-up of 20 months.Absence of the portal vein and polysplenia syndrome is not a contraindication for liver transplantation although an increased post-operative morbidity may be expected.

Three experiments were conducted to examine fact finders' judgments of children's answers to cued recall questions about a recent dental visit. Participants performed better than chance at judging the correctness of the children's answers in all 3 experiments, and judgment accuracy was consistently better when the children's answers were correct. Judgment performance did not decline when confidence information was removed, and when all confidence information was removed, the best performance was obtained by parents and by professionals who work with children. The findings of these experiments provide support for the use of written transcripts in presentations of child testimony and highlight the importance of child- and event-related knowledge in judgments of children's testimony.

Imploding wire arrays on the 20 MA Z generator have recently provided some of the most powerful and energetic laboratory sources of multi-keV photons, including ∼375 kJ of Al K-shell emission (hν ∼ 1–2 keV), ∼80 kJ of stainless steel K-shell emission (hν ∼ 5–9 keV) and a kJ-level of Mo K-shell emission (hν ∼ 17 keV). While the global implosion dynamics of these different wire arrays are very similar, the physical process that dominates the emission from these x-ray sources fall into three broad categories. Al wire arrays produce a column of plasma with densities up to ∼3 × 1021 ions/cm3, where opacity inhibits the escape of K-shell photons. Significant structure from instabilities can reduce the density and increase the surface area, therefore increase the K-shell emission. In contrast, stainless steel wire arrays operate in a regime where achieving a high pinch temperature (achieved by thermalizing a high implosion kinetic energy) is critical and, while opacity is present, it has less impact on the pinch...

Rotator cuff repair is one of the most common surgical procedures done in the shoulder. Traditionally, repair has required an open incision with release of a portion of the deltoid from the acromion. In the past decade, an arthroscopically-assisted, mini-open approach has gained popularity. This has been facilitated by advances in the use of arthroscopy. This trend toward a more minimally invasive approach has continued as arthroscopic techniques continue to improve and advance. An all-arthroscopic approach recently has been used for rotator cuff repairs. The arthroscopic approach offers several advantages including smaller incisions, easy access to the glenohumeral joint for treatment of intraarticular diseases, less soft tissue dissection, and less potential harm to the deltoid. The purpose of the current study is to discuss recent advances in arthroscopic and mini-open rotator cuff repair techniques and to highlight the technical aspects of the mini-open procedures that are important in making the transition to an allarthroscopic rotator cuff repair.

This report contains a summary of the results generated for Task 2.3: Physical Properties Measurement. The aim of this task was to determine the theoretical density of selected samples and from this determine an approximate relationship between open and closed porosity.

A newborn girl with features of Turner and Cri du chat syndromes was found to have a pseudodicentric 5;X chromosome. Her karyotype was 45,X, psu dic(5;X)(p15.2;p22.1). The net result was monosomy for 5p15.2-pter and Xp22.1-pter. Fluorescence in situ hybridization (FISH) showed the Cri du chat region was deleted. Replication banding studies to assess the X-inactivation pattern found only the X portion of the pseudodicentric chromosome to be late replicating without any apparent spread of inactivation into chromosome 5 segment. There are only two cases reported with a dicentric X; autosome. In this paper, we compare the cytogenetics of the present case and those in the literature.

This paper describes the development of a community-based family HIV clinic in south London, an area with one of the highest rates of HIV seroprevalence in the UK. The King's family clinic was developed by broadening existing interdisciplinary services for women with HIV, utilizing the strengths of community-based paediatric care as well as integrating paediatric support from acute hospital-based services. Different models of care for children infected or affected by HIV and problems encountered in developing the service, including ethical dilemmas, and current activity are discussed.

Telemedicine, the delivery of health care with the patient and health professional at different locations, has been around for over 30 years. Its driving force has been developments in communications technology, and as new communications systems are developed health applications are proposed such as supporting the delivery of primary health care to geographically remote areas or regions underserved through the maldistribution of professional expertise. Despite rapid technological advances, evaluations of such systems have been largely superficial, and more thorough evaluations have failed to show significant advantages for more advanced and expensive technology over older technology such as the telephone. Methods for evaluating the impact of particular technologies on the health care system need to be developed and clearer benefits shown in terms of improved standards of care. The development of high speed data transmission links on the information superhighway has stimulated a new burst of activity in the field of telemedicine. The prefix, from the Greek telos, implies only distance, but telemedicine has been defined more recently in terms of advanced communications technology. “Telecommunication that connects a patient and a health care provider through live two-way audio, two-way video transmission across distances and that permits effective diagnosis, treatment and other health care activities.”1 This preoccupation with the latest technology is a symptom of the malaise that has afflicted the field since its inception, and much of the work presented at the Telemed 94 international conference in London last November revealed that the subject is still dominated by advanced communications technology looking for health applications. Telemedicine, however defined, is not new; early reports appeared in the …